Achieving Triple Aim Through Innovative Measurement Approaches
Explore the State Innovation Model Grant's measurement approach for achieving the Triple Aim, focusing on the Total Cost of Care Calculation, its limitations, resource use analysis, and key metrics for evaluating risk-adjusted total costs and resource utilization per member per month.
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The State Innovation Model Grant A Measurement Approach to Achieve the Triple Aim 1
The Total Cost of Care Calculation (TCOC) Analytical framework was designed to support affordability initiatives Systematically pinpoints savings opportunities at the population, provider, condition, procedure and patient-level. Standardized price value (acts in the same fashion as a dollar) 2
It may be the gold standard but It has Limitations Excludes commercial claims for adults over 65 Excludes claims for babies under age 1 Claims are truncated at $100,000 per member Excludes claims for behavioral health and substance abuse treatment Excludes members that have less than 9 months of medical enrollment for the measure period In the model used by Health Partners - included provider groups with at least 600 members smaller practices not included 3
It may be the gold standard but It has Limitations Continued Includes only physicians, physician assistants and nurse practitioners Assigns a specialty to each claim based on the practicing specialty of the serving physician. Includes only the following specialties: family medicine, internal medicine, pediatrics, geriatrics, obstetrics and gynecology Excludes claims not assigned to a specialty Counts each visit once all claims meet the criteria 4
Resource Use Total Care Relative Resource Value (TCRRV) algorithm Quantify resource use for all procedures and selected services in a health care system Facilitates easy comparisons across procedure, peer groups and health care settings (inpatient, outpatient, professional and pharmacy) Identifies overuse/inefficiency and price variation within and among provider groups, employer groups, geographic regions and places of service. Optimizes value for ACOs by easy reporting for large organizations seeking to lower costs by improving resource use and lowering price. 5
The Metrics The final Total Cost of Care and Resource Use measures are expressed as a risk adjusted total cost or resource use per member per month: Risk Adjusted Total Allowed Amount PMPM = (Total Allowed Amount / population membership) / (relative risk score) Risk Adjusted Total Resource Use PMPM = (Total TCRRVsTM / population membership) / (relative risk score) 6
For More Maine SIM Info VISIT: http://www.maine.gov/dhhs/sim/overview.shtml 7
